Anesthesia in the Crosshairs: Surviving a Payer Audit

SUMMARY: Audits of anesthesia records and claims are inevitable. The question is, how well will your group members' documentation hold up under the bright light of scrutiny? A few strategies may help them to survive a payer audit.

Don't think they're not out there. They are . . . just around the corner, looking over your shoulder and ready to pounce. No, we're not referring to a 150-pound panther hiding in the rocky crags of a Western reserve just waiting on some unsuspecting hiker to stroll by, or a 12-foot alligator in a Louisiana lake grinning at the guy who has just taken a tumble while water skiing. No, it's another sort of predator with which we're concerned: the medical auditor.

A Cause for Caution

Without a doubt, those who perform audits for a living are among those of the highest integrity; so, we in no way want to impugn their character or methods. But the fact remains that every payer utilizes individuals who are paid to scrutinize your record documentation and medical claims. That means you are in the crosshairs of claim examiners whose professional life revolves around finding and publishing your mistakes.

When it comes to recovery audit contractors (RACs), much of their income is based on finding discrepancies between the claim form and the medical record. Where they can demonstrate that you owe money back to the payer, the RAC auditor gets to keep a percentage of that remittance. In this way, they are financially incentivized to find errors in your documentation. Their job is to show that your documentation does not support what was listed on the claim form. So, in a very real sense, every provider has a target on his or her back, as these RAC auditors are contracted by every Medicare jurisdiction and each Medicaid program in the 50 states.

Whether it's a RAC auditor, CERT auditor or third-party payer auditor, the point is that anesthesia providers must proceed under the assumption that their claims will eventually come under the scrutiny of some eager individual who lives to find fault with your documentation and ultimately exclaim "gotcha!" On those occasions when they are proven justified in their findings, the consequences can be considerable. For example, Medicare may use the extrapolation methodology to turn five cases with the same deficiency (e.g., adding an extra 5 minutes to the front end of the case), out of 10 reviewed, into 50 percent of all your cases going back a couple of years. The payback in such a scenario can turn into some serious money. Should they find a pattern of intentional fraud, then you're looking at significant fines and potential jail time. This is all the more reason to take your record documentation seriously and look for ways to keep the auditor at bay.

Unlock Your Compliance Plan

One of a medical group's best friends is its corporate compliance plan. A few years ago, the federal government made it mandatory for provider groups to have such a plan in place. We will proceed, then, on the assumption that you have one. We will also assume that it mirrors the model compliance plan for medical groups published several years ago by the Office of Inspector General (OIG) within the U.S. Department of Health and Human Services (HHS). That model plan calls for the incorporation of risk areas that the group wishes to particularly address due to their own unique practice parameters.

We recommend that anesthesia groups review their current compliance plan to see if it: (a) contains sufficient treatment of compliance risks, (b) discusses how to eliminate or mitigate those risks, and (c) contains remediation for providers who continue to color outside the lines. Going over these areas of your compliance plan—in regular meetings, at group retreats and at planning sessions—will help ensure that your group members are aware of the potential pitfalls of improper documentation and thereby lessen the likelihood of their occurrence.

In the end, the compliance plan is only as good as its enforcement. The OIG model compliance plan contains a section on disciplinary action. If you have a provider who has been called out on more than one occasion about consistently listing both their start and stop time in 5-minute increments, for example, there needs to be some type of punitive action levied against that provider. The potential actions should be listed in the compliance plan (so that no one can plead ignorance) and should be assessed (so that the plan has actual teeth). If asking nicely doesn't' work, perhaps a $50 fine will.

Revise Your Record Template

So much of a group's tendency toward documentation deficiency can be turned around by simply ensuring they have a compliance-friendly anesthesia record template. If it's clear that some of your providers are making the same mistakes, it's important to ask if this is simply due to the function of the record. Does the record contain sufficient prompts, fields and attestation boxes to keep providers within compliant parameters? If not, now may be the time to make some revisions to your record template.

Through our encouragement, we have seen many groups over the years make positive changes to their anesthesia record format, so that it better captures data points from a billing and compliance perspective. For example, some groups added additional spaces for signatures to account for relief situations or additional start/stop fields to capture multiple discontinuous time blocks. Others embedded preformulated medical direction attestation statements (e.g., "Present for Induction," Present for Emergence," "Monitored Some Portion") with adjacent areas for the provider's initials.

We realize that getting these changes made is not always easy and cannot be done overnight. Facility form committees have to be consulted, and there are costs for printing new forms. For those using an electronic medical record (EMR), you will also have to work with your IT staff to find ways to make the record more compliance friendly. If you need help in this area, we have EMR-specific experts who can assist you in communicating what data points are required for compliant billing. Revising your record template can automatically lead to dramatic decreases in errant documentation and is one of the best ways to leave an over-anxious auditor with nowhere to go.

Question the Findings

If following your compliance plan and revising your template still aren't enough to convince an auditor to give you a clean bill of health, there is another option still available to you. You should have your team go over each item where the auditor claimed a documentation deficiency occurred. Verify whether or not their allegation of error is correct. Often times, we have found that these payer-associated auditors are not as proficient in the rules of anesthesia compliance as one would think. They may not understand the principles of time documentation or they can't distinguish between modes of anesthesia and postoperative pain procedures, etc.

We have discovered over the years that auditors of anesthesia claims—particularly those employed or contracted by payers—are often simply wrong in their allegations. That's why it's important to challenge their findings. Demonstrate to them how and why they're wrong relative to case A, B, C, etc. Since there are financial implications, your attention to this matter is warranted. If you have any questions, please contact your account executive or reach us at info@anesthesiallc.com.

With best wishes,

Tony Mira
President and CEO